Provider Demographics
NPI:1396812665
Name:KINARD, ELIZABETH A (MS)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:KINARD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2679 W FOREST RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9472
Mailing Address - Country:US
Mailing Address - Phone:815-233-6162
Mailing Address - Fax:815-233-6167
Practice Address - Street 1:31 STATE RT 23 N
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419-1419
Practice Address - Country:US
Practice Address - Phone:973-209-9085
Practice Address - Fax:815-233-6167
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00223700101YP2500X
PAPC001943101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021091Medicaid